Student Registration Form

Primary Family Address

Family Name

Address

Primary E-mail

This will be the main e-mail address we will use to communicate with your family.

Primary Phone

This will be the main phone number we will use to communicate with your family.

Number of Children

Number of Children you will be registering today

Number of Children (Alternate Pricing)

Number of Children you will be registering today

Father's Name

Deceased

Yes No

E-mail

Marital Status

Religion

Cell Phone

Mother's Name

Deceased

Yes No

Maiden Name

E-mail

Marital Status

Religion

Cell Phone

Custody Information

Are there any custody issues we should be made aware of? If there is a custody agreement please send a copy to the Religious Education Department.

Child is in custody of

Both Parents Mother Father Other: ‎

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What is your language preference for your children's classes?

English Spanish

Child 1

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2019

School Grade

School Grade in Fall 2019

School

School District

Individualized Education Program (IEP)

No Yes

Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)

Medical/Learning Data

*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with an intellectual disability, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."

Is your child a New or Returning Student to our program?

New Student Returning Student

Child 1 Sacraments

Previous Religious Education Experience

Please provide student's last grade completed and Parish Name / Address

If registering for first time your Child's Baptismal Certificate must be submitted to the office.

Date of Baptism

Church of Baptism

Church Name, City & State

Date of First Communion

Church of First Communion

Church Name, City & State

Child 2

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2019

School Grade

School Grade in Fall 2019

School

School District

Individualized Education Program (IEP)

No Yes

Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)

Medical/Learning Data

*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with an intellectual disability, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."

Is your child a New or Returning Student to our program?

New Student Returning Student

Child 2 Sacraments

Previous Religious Education Experience

Please provide student's last grade completed and Parish Name / Address

If registering for first time your Child's Baptismal Certificate must be submitted to the office.

Date of Baptism

Church of Baptism

Church Name, City & State

Date of First Communion

Church of First Communion

Church Name, City & State

Child 3

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2019

School Grade

School Grade in Fall 2019

School

School District

Individualized Education Program (IEP)

No Yes

Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)

Medical/Learning Data

*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with an intellectual disability, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."

Is your child a New or Returning Student to our program?

New Student Returning Student

Child 3 Sacraments

Previous Religious Education Experience

Please provide student's last grade completed and Parish Name / Address

If registering for first time your Child's Baptismal Certificate must be submitted to the office.

Date of Baptism

Church of Baptism

Church Name, City & State

Date of First Communion

Church of First Communion

Church Name, City & State

Child 4

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2019

School Grade

School Grade in Fall 2019

School

School District

Individualized Education Program (IEP)

No Yes

Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)

Medical/Learning Data

*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with an intellectual disability, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."

Is your child a New or Returning Student to our program?

New Student Returning Student

Child 4 Sacraments

Previous Religious Education Experience

Please provide student's last grade completed and Parish Name / Address

If registering for first time your Child's Baptismal Certificate must be submitted to the office.

Date of Baptism

Church of Baptism

Church Name, City & State

Date of First Communion

Church of First Communion

Church Name, City & State

Child 5

Name

Gender

Male Female

Date of Birth

Place of Birth

City & State

Religious Education Grade

Grade in Fall 2019

School Grade

School Grade in Fall 2019

School

School District

Individualized Education Program (IEP)

No Yes

Please list all pertinent medical/learning data so we can best meet the needs of your child. (Medical Conditions/Allergies - Prescribed Medications - Disability*/Learning Support Services)

Medical/Learning Data

*As defined by Individuals with Disabilities Education Act (IDEA), the term "child with a disability" means a child: "with an intellectual disability, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities and who, by reason thereof, needs special education and related services."

Is your child a New or Returning Student to our program?

New Student Returning Student

Child 5 Sacraments

Previous Religious Education Experience

Please provide student's last grade completed and Parish Name / Address

If registering for first time your Child's Baptismal Certificate must be submitted to the office.

Date of Baptism

Church of Baptism

Church Name, City & State

Date of First Communion

Church of First Communion

Church Name, City & State

Document Uploads

File Uploads

Add files

Drop files anywhere to add

Please upload any documents required by the office with this form. (Baptism, Custody, etc.)

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Emergency Contact

Emergency Contact Name

If we are unable to contact a parent in the event of an emergency, whom should we contact?

Relationship

Emergency Contact Phone

Terms & Conditions

I understand that in the case of injury or illness, every effort will be made to contact me in a medical emergency. In the event I cannot be reached, I give permission to parish staff to secure all proper and necessary treatment for my child(ren). I understand that no liability is assumed by the church or the Archdiocese for claims that may arise.

I agree

Parental Consent for Medical Care: In case of an emergency, I give permission for my child to receive emergency medical treatment and, if necessary, be transported to the nearest appropriate medical facility.

I agree

I understand that photos of my child(ren) may be taken and used in Parish publications including web and print media.

I agree

Sacramental Fees

Current Date

Total Normal

Payment is required at the time of registration. Your child will not be assigned to a class without full payment.

If your family is experiencing financial difficulty and you would like to create a payment plan, please call for an appointment to register in person. Please do not delay in registering due to finances.

Total Amount

Verification